- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,467.12 / $2,467.12 / $2,467.12
| Facility | | $2,467.12 | $2,467.12 | $2,467.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,467.12 / $2,902.82 / $3,490.07
| Professional | | $2,467.12 | $2,902.82 | $3,490.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.95 / $413.45 / $624.47
| Facility | | $57.95 | $413.45 | $624.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.11 / $56.11 / $56.11
| Professional | | $56.11 | $56.11 | $56.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $486.93 / $486.93 / $6,226.64
| Facility | | $486.93 | $486.93 | $6,226.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.93 / $650.55 / $2,679.32
| Professional | | $340.93 | $650.55 | $2,679.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.47 / $1,050.51 / $3,403.81
| Professional | | $480.47 | $1,050.51 | $3,403.81 |